title: A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts.
abstract: BACKGROUND
  intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC.
  
  
  METHODS
  A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system.
  
  
  RESULTS
  Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β-D-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5-7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved.
  
  
  CONCLUSIONS
  Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.
authors.affiliation: Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy, mattba@tin.it.
authors.forename: Matteo
authors.initials: M
authors.lastname: Bassetti
authors.forename: Monia
authors.initials: M
authors.lastname: Marchetti
authors.forename: Arunaloke
authors.initials: A
authors.lastname: Chakrabarti
authors.forename: Sergio
authors.initials: S
authors.lastname: Colizza
authors.forename: Jose
authors.initials: J
authors.lastname: Garnacho-Montero
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Kett
authors.forename: Patricia
authors.initials: P
authors.lastname: Munoz
authors.forename: Francesco
authors.initials: F
authors.lastname: Cristini
authors.forename: Anastasia
authors.initials: A
authors.lastname: Andoniadou
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Viale
authors.forename: Giorgio Della
authors.initials: GD
authors.lastname: Rocca
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Roilides
authors.forename: Gabriele
authors.initials: G
authors.lastname: Sganga
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Walsh
authors.forename: Carlo
authors.initials: C
authors.lastname: Tascini
authors.forename: Mario
authors.initials: M
authors.lastname: Tumbarello
authors.forename: Francesco
authors.initials: F
authors.lastname: Menichetti
authors.forename: Elda
authors.initials: E
authors.lastname: Righi
authors.forename: Christian
authors.initials: C
authors.lastname: Eckmann
authors.forename: Claudio
authors.initials: C
authors.lastname: Viscoli
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Shorr
authors.forename: Olivier
authors.initials: O
authors.lastname: Leroy
authors.forename: George
authors.initials: G
authors.lastname: Petrikos
authors.forename: Francesco Giuseppe
authors.initials: FG
authors.lastname: De Rosa
mesh_terms: D018784:Abdominal Abscess / Q000188:drug therapy / Q000382:microbiology; D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D001431:Bacteriological Techniques; D002175:Candida / Q000302:isolation & purification; D002177:Candidiasis / Q000188:drug therapy* / Q000382:microbiology; D004271:DNA, Fungal / Q000032:analysis; D006801:Humans; D059413:Intraabdominal Infections / Q000188:drug therapy* / Q000382:microbiology; D016533:Mycological Typing Techniques; D010532:Peritoneal Diseases / Q000188:drug therapy / Q000382:microbiology; D016133:Polymerase Chain Reaction; D012307:Risk Factors
chemical_list: D000935:Antifungal Agents; D004271:DNA, Fungal